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Abstract

This research aimed to inform the development of a health communication campaign to increase the uptake of COVID-19 prevention behaviors among university students. Twenty-eight students attending a mid-sized public university in the southeastern United States and 84 parents or guardians of university students were recruited. The study included an online survey assessing COVID-19 prevention behaviors, perceived susceptibility to COVID-19, perceived severity of COVID-19, and semi-structured interviews to elicit beliefs on COVID-19 prevention behaviors. Students and parents/guardians reported that getting COVID-19 was possible but not necessarily likely. COVID-19 was seen as serious and at least somewhat severe. Dominant interview themes for benefits, barriers, response efficacy, and self-efficacy related to prevention behaviors are reported. Overall, perceptions of behavioral benefits, barriers, and response efficacy were often shared by parents and students but varied across behaviors. These data provide insights for future campaign development for the control of infectious diseases among college students.

Keywords

COVID-19 Health Belief Model Extended Parallel Process Model young adults university students

After shifting classes online in early 2020 as the Coronavirus Disease 2019 (COVID-19) pandemic spread worldwide, many institutions of higher learning closed campuses, and students remained home throughout the summer of 2020 (Smalley, 2021). As colleges and universities started planning to bring students back to campus for the fall semester, the authors took part in a university work group tasked with assessing the information needs of university stakeholders to inform the university’s response to COVID-19. This theoretically driven formative research conducted with parents and students informed the development of a health communication campaign for students to encourage students to engage in behaviors to reduce the spread of COVID-19. We report on this formative research and present implications for future disease outbreaks on college campuses.

Prior Research to Inform Covid-19 Communication Campaigns

Prior research to inform college communication campaigns to encourage COVID-19 prevention strategies is limited. Mackert et al. (2020) reported findings from focus groups conducted with University of Texas at Austin students, faculty, staff, and parents to test COVID-19 prevention messages. Some findings, such as those that identified adverse audience reactions to message concepts, underscore the importance of conducting formative research to inform messages. Chesser et al. (2020) report on an assessment of COVID-19 knowledge and beliefs conducted in March 2020 with a sample of college students at a university in the midwestern United States. Survey results indicated that the internet and social media were students’ primary and preferred sources for COVID-19 information. Most students surveyed (79%) identified handwashing as an effective prevention strategy, and 68% of students were amenable to receiving a COVID-19 vaccine when it became available.

There is also limited guidance and data available to inform messaging strategies for specific prevention behaviors. Barile et al. (2020) reported on data from a survey of U.S. adults conducted in May and June 2020. Their cross-sectional data suggest that higher confidence in one’s ability to wear a face covering, and higher perceived importance of the use of a face covering were positive and significant predictors of intention to wear a face covering. Botta et al. (2008) conducted formative research for a handwashing campaign using focus groups with college students. At the time the research was conducted (before the threat of COVID-19), “common threats used in hand-washing campaigns such as spreading germs and getting sick were not relevant to the students in the target audience” (p. 373). Finally, Bonell et al. (2020) provide key recommendations from behavioral science in public health campaigns to encourage social distancing including finding ways to build self-efficacy with messaging; creating campaigns with a clear “theory of change” (p. 618) and working with audience groups to design and pilot interventions.

Theoretical Framework

Prior research has demonstrated that health communication campaigns are more effective when they are informed by theory and formative research (Noar, 2006). Our inclusion of family members, specifically parents, was informed by the contextual components of Bronfenbrenner’s (1977, 1979) Bioecological Systems Theory. The college student does not operate in isolation, but is influenced by various systems including friendships, family, and the college environment, among others (Bronfenbrenner, 1992, 2005). Therefore, it was necessary to understand perceptions of COVID-19 health-related behaviors among both students and their parents to inform a university communication campaign. This is consistent with other campaigns that have utilized a family perspective to understand and inform student communication (Jones et al., 2009; McMillan, 2020). In line with recommendations from Bonell et al. (2020), we followed a formative research and campaign development approach adapted from Witte et al. (2001) that incorporates constructs from two theories often used in health communication: the Health Belief Model (Rosenstock, 1974) and the Extended Parallel Process Model (EPPM; Witte, 1992).

Health Belief Model

The Health Belief Model (HBM; Rosenstock, 1974) developed largely to explain preventive health behavior, includes several key predictors of behavior: perceived susceptibility to a health problem or condition, perceived seriousness of the health problem, perceived benefits of taking action, perceived barriers to taking action, and cues to action. The HBM has been used to guide the development of health communication campaigns across multiple topics and audiences, including college students (e.g., Case et al., 2016; Sundstrom et al., 2018). In recent survey research with students at a midwestern university in the United States, Alsulaiman and Rentner (2021) used the Health Belief Model to examine adherence to COVID-19 prevention behaviors, they found a negative relationship between perceived barriers and likelihood of adopting healthy behaviors and a positive relationship between cues to action and COVID-19 prevention behaviors.

Extended Parallel Process Model

The EPPM (Witte, 1992) proposes a process through which individuals respond to fear appeals that include threat components (severity and susceptibility) and efficacy components (response efficacy and self-efficacy). The EPPM predicts that, when both threat and efficacy are high, people will be more likely to make adaptive changes to “avert the threat” (Witte, 1992, p. 338). The EPPM has been used often in formative research and to guide the development of health communication campaigns (e.g., Cho & Witte, 2005), including messages developed for college populations (e.g., Egbert et al., 2014; Escoto et al., 2021). Additional prior research uses the EPPM to explain behaviors relevant to COVID-19 prevention such as handwashing (Botta et al., 2008) and wearing personal protective equipment (Shirahmadi et al., 2020).

To our knowledge, no published research has employed the EPPM to inform COVID-19 prevention efforts among college students, and few have used the HBM, thus our research contributes to the literature by extending the application of these theories into the context of college health campaigns related to COVID-19.

Method

This formative research employed both survey research and semi-structured interviews to inform the campaign. The research was approved by the institutional review board at the authors’ institution, and researchers obtained informed consent from participants. Data were collected in June and July 2020.

Participants

Participants included students and parents or guardians of students at a mid-sized public university in the Southeastern United States. Of approximately 22,000 students enrolled in the fall of 2022, 80.8% were undergraduate students, 51.4% identified as women, 0.5% identified as American Indian or Alaskan Native, 1.6% identified as Asian, 15.2% identified as Black or African American, 3.8% identified as Hispanic, and 72% identified as White (Mississippi State University, 2021). Of approximately 18,000 undergraduates, 22% were classified as Freshmen, 17% were sophomores, 24% were juniors, and 37% were seniors (Mississippi State University, 2021). A diverse cross-section of university students was nominated by the interdisciplinary work group (which included faculty, staff, and student representatives from units across campus). Students were purposively selected to maximize diversity in terms of major, classification, student organizations, and other characteristics and invited through email to participate in the research. Of 44 students invited to participate, 31 started the survey and 28 completed it. All 28 students who completed the survey were invited to participate in an individual interview, and 14 completed an interview. Parents and guardians were recruited through an email distributed to a university parent email list. Ninety-one parents began the survey, and 84 completed it. Of these 84, 29 were randomly selected and invited to participate in an interview, and 16 completed an interview. Participant characteristics are presented in Table 1. Students who participated in interviews had demographic characteristics similar to those of the larger student body; 78.6% were undergraduates (compared with 80.8% in the student body), 57.1% identified as female (compared with 51.4%), 21.4% identified as Black or African American (compared with 15.2%), and 78.6% identified as White (compared with 72%). Students responding to the survey represented majors from five different colleges and represented approximately 40 student organizations (including student government, Greek organizations, athletics, and others). We also had participants who reported having no involvement in organizations. Of parents who participated in interviews, 62.5% identified as female, 12.5% identified as Black or African American, and 68.8% identified as White. Parents of undergraduate students (vs. parents of graduate students) were overrepresented.

Table 1

Participant Characteristics

Characteristic	Student survey participants	Student interview participants	Parent/guardian survey participants	Parent/guardian interview participants
n	28	14	84	16
Age (students), M (SD)	21.5 (1.93)	21.5 (1.99)
Age (parents)
35–44, % (n)			4.8 (4)	12.5 (2)
45–54, % (n)			69.0 (58)	68.8 (11)
55–64, % (n)			26.2 (22)	18.8 (3)
Female, % (n)	67.9 (19)	57.1 (8)	66.7 (56)	62.5 (10)
Race
White, % (n)	82.1 (23)	78.6 (11)	79.8 (67)	68.8 (11)
Black or African American, % (n)	17.9 (5)	21.4 (3)	9.5 (8)	12.5 (2)
Asian, % (n)	0 (0)	0 (0)	2.4 (2)	0 (0)
Other, % (n)	0 (0)	0 (0)	6.0 (5)	12.5 (2)
Prefer not to answer, % (n)	0 (0)	0 (0)	6.0 (5)	6.3 (1)
Hispanic, Latinx, or Spanish origin, % (n)	0 (0)	0 (0)	3.6 (3)	0 (0)
Student classification: Undergraduate, % (n)	78.6 (22)	78.6 (11)	97.6 (82)	100.0 (16)

Note. Reported race percentages may not add to 100 because participants could select multiple races.

Instruments

Survey

Participants completed a web-based survey administered through Qualtrics that collected characteristics including age, gender, race, ethnicity, student classification, and education (parent/guardian survey only). Additional measures not reported in this manuscript are in the online supplement: behavior to prevent the spread of COVID-19, personal experience with COVID-19, perceived susceptibility to and severity of COVID-19 (adapted from Witte et al., 1996), and frequency of actions to reduce the spread of COVID-19.

Interview

Structured interviews followed an interview schedule to collect data on five key infection control behaviors: using hand sanitizer (washing hands was later added), wearing a face covering, physical distancing, participating in a daily COVID-19 screening, and staying home when sick (Centers for Disease Control and Prevention, 2020). For each behavior, we asked questions related to constructs of the Health Belief Model and EPPM including barriers to performing each behavior, benefits of performing each behavior, perceived response efficacy of each behavior to prevent the spread of COVID-19, self-efficacy to perform each behavior, and key referents who would influence each behavior. Interview questions were adapted from an existing instrument (Witte et al., 2001), and the interview schedule for parents and guardians differed from the student version in that it omitted self-efficacy and referents. The order of prevention behaviors was varied among participants to gather equal amounts of feedback about each behavior.

Interviewers elicited perceived COVID-19 consequences by asking “What do you see as the possible negative consequences of getting COVID-19? List all of the possible consequences you can think of.” Then, the following set of questions was repeated for each of the five behaviors (with hand washing added as a sixth behavior in later interviews). Beliefs were elicited by asking participants “What thoughts come to mind when you think about [your student] [behavior]? List all of the thoughts that come to mind.” Barriers were elicited by asking “What might keep [you/your student] from [behavior]?” Benefits were elicited by asking “What benefits do you see from [behavior]?” As defined by Witte (1992), response efficacy is “an individual’s beliefs as to whether a response effectively prevents the threat” (p. 332). For using hand sanitizer, hand washing, and physical distancing, perceived response efficacy was elicited by asking “Do you agree or disagree with the statement ‘[Behavior] will keep me from experiencing the negative consequences of COVID-19’? Please explain why you agree or disagree.” For wearing a face covering, participating in screening, and staying home when sick, statements read “[Behavior] will help prevent the spread of COVID-19,” as those behaviors were perceived as behaviors that primarily protected others. Perceived self-efficacy was elicited by asking “Do you agree or disagree with the statement ‘I am confident that I could [behavior]’? Please explain why you agree or disagree.” Important behavioral referents were elicited by asking students to “Please list the people or groups who have an important influence on your [behavior].”

Analysis

Interviews were recorded, transcribed verbatim, and coded by three authors and two graduate assistants using NVivo. Interviews were first coded deductively as pertaining to one of the behaviors and one of the theoretical constructs. Then, within each behavior and construct, the responses were coded inductively for emergent themes using the thematic analysis procedure described by Braun and Clarke (2006). The entire coding team coded two transcripts together to establish coding procedures. The team then divided the transcripts, generated initial codes, and met weekly to review transcripts and coding procedures. After all transcripts had been coded, three authors worked together to review initial codes and search for themes and illustrative quotes. Two of these authors then named and defined themes and selected final quotes for each theme. The remaining author reviewed and approved final themes, definitions, and quotes.

Results

Consequences

Four themes relating to the consequences of experiencing the coronavirus were identified. First, participants acknowledged the physical health consequences of the coronavirus associated with morbidity and mortality. Second, participants noted consequences related to the social, mental, and emotional effects of the coronavirus. Third, participants reported educational repercussions, including the adverse impact on academic participation and performance. Finally, participants noted the economic consequences of the coronavirus, including losing income, changing employment status, or depending on care while experiencing symptoms. Themes, definitions, and descriptive quotes to support the themes are reported in Table 2. Some themes were identified only in parent participants or student participants, and these differences are indicated in the table.

Table 2

Themes Related to Consequences of COVID-19

Theme	Definition	Quote
Health consequences	Physical health consequences of COVID-19 as a result of morbidity, and potentially leading to mortality	“Negative consequences, at worst death. Which hopefully not not something everyone experiences. Fatigue, loss of taste, loss of smell, sometimes temporary, sometimes not so much. Consequences I think that there’s also been some reports of lung damage. I think there’s just a lot that they don’t know. So some of the some of the consequences, the effects after after you get it, are still a little hazy. Then in children, and I think this only applies to smaller kids, not like the age kids I have, there’s that inflammatory response that’s happening weeks after they seem to have contracted it. Generally, asymptomatically.” P06
		“I have a cousin who passed away from COVID-19” P63
		“. . . it’s seems to have some pretty severe health effects on people, you know, generally older people, but not necessarily just older people because we’ve, I’ve know I’ve heard a lot of cases of young people, middle aged people and older people. Obviously, it takes the respiratory system pretty severely and seems to be pretty aggressive to the people that are not lucky enough to be asymptomatic . . .” S14
Social consequences	Social, mental, and emotional effects on well-being because of social isolation, stigma, fear of spreading COVID-19 to vulnerable populations, or fears that others will not take virus seriously	“Not being able to spend what could be a final days with your family. Feeling ostracized.” P05
		“It’s the fear of spreading it to to vulnerable populations of grandparents and maybe some elderly in the neighborhood. So, you know, [inaudible], I think our, the American culture of big bear hugs [inaudible] you know, handshaking probably over for a long time. I think, I think we’re, we’re in a new normal that’s going to just it’s it’s just gonna have to be different. So I think we’ve all experienced that [inaudible] fear of spreading it to vulnerable populations.” P03
		“So, the biggest thing to me has in the possibility, that could spread it to those who are more vulnerable to disease. You know, any anyone I might come in contact with that’s either older or has a preexisting condition.” S20
		“Well, from what I’ve seen, and from what I’ve heard, a possible consequences are—besides the actual health consequences—just the negative stigma it holds. When you do contract the virus, people do look at you differently. The way that they interact with you is very different and not just as safety precautions, but just socially as well. They try to distance themselves and you’re seen more as a pariah.” S05
Educational consequences	Negative effects on academic participation and performance	“Getting behind in a school work, like missing class, whether it would be online, or in person, and then trying to catch up.” P50
		“. . . not being able to go to school . . .” S13
		“I think that it can get you behind in school, set you behind if you have something that you’re training for physically, like you can set behind in that and I know that a lot of people have symptoms long time after they get over the sickness. And that can be a real drag really depressing.” S25
Economic consequences^a	Financial ramifications of COVID-19, such as losing income or employment	“. . . the economic impacts such as losing jobs having to miss work . . .” S13
Economic consequences^a		“I think that it can have financial ramifications and consequences on other people who have to take care of you. I think there’s definitely consequences.” S25

Note. The letter and number following each quote indicates the participant to whom the quote is attributed, with P indicating the quote is from a parent or guardian and S indicating the quote is from a student.

This theme is only present in student data.

Benefits, Barriers, Response Efficacy, and Self-Efficacy

Themes related to cleaning hands, wearing a face covering, physical distancing, screening, and staying home were identified and categorized according to the constructs of benefits, barriers, response efficacy, and self-efficacy. Themes are presented in Table 3, and each theme is supported by a definition and illustrative quotes by at least one parent or guardian and one student. Some themes were identified only in parent participants or student participants, and these differences are reflected in the table.

Table 3

Themes Related to Benefits, Barriers, Response Efficacy, and Self-Efficacy, by Behavior

Construct	Theme	Definition	Quote
Cleaning hands
Benefits	Reduce the risk of spread of COVID-19 and germs in general	Lessening the chance of getting or spreading germs	“I mean, it helps, you know, keep down the spread of COVID-19, or just germs in general.” P63
	Reduce the risk of spread of COVID-19 and germs in general	Lessening the chance of getting or spreading germs	. . . “if the virus is on my hands or it, the, the benefit of it would definitely be to just kill the kill the germs, which should be done anyways on a normal basis regardless of coronavirus or not.” S13
	Personal hygiene	General cleanliness practices	“It’s just good for hygiene practice.” P10
	Personal hygiene	General cleanliness practices	“Again, just, you know, maintaining hygiene and being able to, you know, cleanse your hands and not spreading the disease.” S20
Barriers	Accessibility	Access to hand washing locations or hand sanitizer products or stations is a barrier to cleaning hands	“So, the accessibility of hand washing stations, not just in bathroom facilities. I think would go a long ways. You’re encouraging students to do that regularly.” P03
	Accessibility		“I think that it’s sometimes really hard to find hand sanitizer” S25
	Time sensitivity	Not having enough time including rushing to class is a barrier to cleaning hands	“Probably being in a hurry to go somewhere and not allowing enough time to go.” P44
	Time sensitivity		“Time, but not having the time to run to your bathroom and wash your hands.” S23
	Carrying sanitizer	Carrying sanitizer may be burdensome	“Not having it, not being able to find it, forgetting it. With a boy, it’s where to put it too, because generally they’re not caring a purse but generally, they have a backpack.” P50
	Carrying sanitizer	Carrying sanitizer may be burdensome	“Not having any or not having any with me.” S23
	Forgetfulness	Failing to remember to clean hands or use sanitizer	“Same as always the forgetfulness. But I think if you’re, you know, you have things posted to wash your hands and, you know, there’s close proximity to hand washing stations. I think it [inaudible], but kind of forgetfulness forgetting to do it.” P03
	Forgetfulness	Failing to remember to clean hands or use sanitizer	“Honestly, I’m a very forgetful person, so I touch my glasses a lot. So, when I touch my glasses and it gets on my glasses, and then I touch my glasses again, and then I touch my mouth and then I’ve been very cautious with that. But I think, I forgot, I forgot a lot.” S04
	Unconcerned	One may be unconcerned regarding the need to clean one’s hands	“I think it would come down to arrogance. It’s not gonna happen to me.” P26
	Unconcerned		“If you’re in a group of people who maybe don’t take that stuff seriously” S18
	Sensitivity	A person’s skin may be sensitive to sanitizers or soaps which may be a barrier to keeping hands clean	“I don’t, you know, I think that, you know, as long as they aren’t allergic and have a skin allergy to it . . .” P62
	Sensitivity		“I’ve had instances where I’ve touched my face and my eyes did start burning because the hand sanitizer.” S13
	Constant contact with multiple surfaces	Enhanced awareness regarding the frequency in which individuals touch various surfaces in the college environment	“. . . you know, just touching something in general. You’re not gonna rush out and wash your hands. And, you know, the fact that at college, you have so many different surfaces that so many students are touching. Yeah. It’s just not a, it’s just not normal for you to want to do that all the time.” P56
	Constant contact with multiple surfaces		“I mean, hand washing. I think it, I don’t run to the bathroom just to wash my hands every time I touch something, but if I go to the bathroom, 100% I’m gonna wash my hands. So, I think it’d probably be a little less convenient than hand sanitizer and, like, earlier, even harder to enforce.” S09
Response efficacy	Concern	Apprehension that cleaning hands will reduce the spread of the coronavirus	“I think we’re getting ourselves. I don’t think I really have very little expectation that hand sanitizer is an effective method to kill that virus.” P54
Response efficacy	Concern		“. . . I don’t think completely eradicates it.” S04
	Limitations of cleaning hands	There are limitations of handwashing to be effective to reduce the spread of the coronavirus if in the air	“. . . it could just be in the in the air and they can inhale it. So, hand washing won’t do anything. If somebody coughs on them.” P04
	Limitations of cleaning hands		“I don’t think it’s a hundred percent foolproof because if I understand correctly, it’s, it’s more about like, if someone coughs near you or something . . .” S09
	Cleaning hands is helpful	Agreement that cleaning hands will reduce the spread of coronavirus	“Well, we have anti-bacterial liquid soap at every sink in our house, and we got on board with the hand washing . . .” P54
	Cleaning hands is helpful		“You know, just another simple way to, to keep yourself from these, you know, I think you just put it on, rub your hands and you’re good to go got it.” S20
	Handwashing versus hand sanitizing	Comparing hand washing with sanitizer as effective measure to combat the coronavirus	“But if you read about how the washing hands thing works, it’s not just quick hand washing that will kill that virus or even break it down. You need heat, you need so soap, you need everything to get through it. I just can’t see where you can get that with hand sanitizer.” P54
	Handwashing versus hand sanitizing		“Yes, GermX is great in the short term, but it’s not going to be as effective as washing your hands.” S18
	Quality of hand sanitizers	The standards of hand sanitizer quality were brought into question	“I mean, we hope that it’s a high quality. So, I, I do question some of the hand sanitizers it’s out there, whether it meet some kind of standard” P03.
	Quality of hand sanitizers		“Well, I know that it’s supposed to kill germs so . . .” S14
Self-efficacy	Condition of self-efficacy	Availability and accessibility of sanitizer and hand washing locations may limit one’s confidence in performance	“I think the biggest thing is just the supply of it around around campus, you know, if it’s not available, then, you know, and I can have my own too, but I think it helps a lot of people and encourages a lot of people with, if it’s available. Yeah, if they, if, if [University] puts it around, you know, classrooms and stuff to, for people to be able to use it.” S20
	Condition of self-efficacy		“I agree that I am confident in using hand sanitizer. I just have to remember to use it. But I probably, if I remember, if they’re like, stations posted, I’m definitely gonna use it.” S04
	Normalcy	Using sanitizer has become a routine and students are already doing this	“It’s usually kinda like second nature to use hand sanitizer now after touching things.” S05
	Normalcy		“I feel like you get it’s like it’s become routine now. And I always have one of those little bottles of it. It’s in my purse. It’s in my pocket. Like, I’ll definitely have it with me.” S08
Wearing a face covering
Benefits	Prevents spread	Reduces the transmission of the coronavirus from sick people to others	“It helps to prevent the spread.” P05
	Prevents spread		“Just, ah, like prevention of spreading the disease . . . So, if someone does have it and is sick. It blocks it before it gets anywhere else in the air.” S09
	Self-protection	Reduces individual likelihood of contracting coronavirus	“Well, hopefully, you minimize the chances that she [student] will pick up COVID.” P04
	Self-protection	Reduces individual likelihood of contracting coronavirus	“Benefits I see, from what I know, the virus is airborne, so that helps keep it away, just from myself. And if I’m wearing a face covering and I'm also six feet away from someone, that drastically decreases a chance of contracting any type of germs or bacteria.” S05
	Limits on benefits	Perceived limitations of the benefits of face coverings	“I don’t see it being practical and I don’t see a benefit because they’re especially because they [young adults] are a low risk.” P69
	Limits on benefits	Perceived limitations of the benefits of face coverings	“Helping reduce the spread of COVID. If it’s worn accurately . . . If it’s . . . it’s outside and there’s nobody around, then, I mean, I feel like it’s not very beneficial.” S23
Barriers	Physical discomfort	The act of feeling physically uncomfortable for a person wearing a face covering	“Just the fact of yeah, they’re not comfortable.” P56
	Physical discomfort		“That they’re uncomfortable” S09
	Social pressure	The perceived judgment of others or desire to conform to social norms to not wear a face covering	“But, I know they’re not cool. And people are gonna probably make fun of you. Oh, look at, you know. “Why are you wearing this? You’re a germaphobe.” All of this stuff. But I think, at this point, I’m hoping that people are starting to realize that yeah, it might not be cool, but it’s what needs to happen.” P04
	Social pressure		“I think for a lot of people maybe, you know, peer pressure or something like that, some kind of anxiety-based thing, they might feel like they’re gonna get judged for wearing a mask. If other people don’t think it’s necessary, or they might think people are gonna look at them funny for wearing one.” S14
	Access	Concerns about the obtainability of face coverings	“So, if you buy those disposable ones, a lot of them say wear them only once and throw them away. So, maybe they would run out of a face mask so to speak. Secondly, if they have a cloth face masks, maybe they worn it a couple of times, and they feel like it’s dirty, you know, and they haven’t had a chance to wash it. So maybe just not having a clean face mask.” P17
	Access	Concerns about the obtainability of face coverings	“I think one, first off, just like the GermX availability, affordability.” S15
	Forget	The inability of students to remember to wear a face covering	“I think forgetfulness” P03
	Forget		“I’m a very forgetful person. So, I might have it in my backpack and when I see someone wear their mask, I’m like, oh Lord, I totally forgot my mask. So, I think personally, with me, I don’t see a, I don’t see a problem with me wearing it in public. I just gotta remember to wear it.” S04
	Adherence	Internal prompts that influence one’s willingness to wear a face covering	“It’s, you know, I can make my own decisions . . . and I don’t think I need it.” P62
	Adherence		“. . . only thing that I can think of that would keep me from wearing it would be either just didn’t feel like it, in all fairness . . .” S06
	Difficulty interacting^a	Ways in which using a face covering inhibit interpersonal interactions	“. . . it’s hard to tell when people are smiling or laughing or doing all this, because the face covering. You know, sometimes it’s hard to hear people, especially if they tend to mumble and they’re wearing the face covering.” P04
	Difficulty interacting^a		“I never realized how much I rely on lip reading. So, if you’ve got a face mask, and you can't see someone’s lips, you almost have to lean in to hear them better.” P67
Response efficacy	Helps control spread of germs	Belief that wearing a face covering is generally accepted as a strategy for reducing the spread of coronavirus	“Yes, I do agree with that, because it helps keep people who may not know that they have COVID-19 from spreading it through speaking and sneezing and coughing.” P06
	Helps control spread of germs		“One hundred percent . . . it does cut down . . .” S08
	Role of adherence	Highlights the role of population compliance in prevention recommendations	“. . . you need a hundred percent compliance” P03
	Role of adherence		“It would definitely help. Like I said before the more people wear it, the better the suppression of the of the coronavirus would be.” S13
	Inferiority of cloth masks	Perceived lack of effectiveness of cloth masks in comparison to N95 masks	“We don’t really know if a cloth mask prevents the spread. It really doesn’t protect you, just cloth mask versus, you know, an N-95 type mask or respirator type system actually protects you as individuals.” P03
	Inferiority of cloth masks		“I think if it is not a, an actual facemask, wearing a piece of fabric that you’ve tied a string to and wear around your face is not gonna do anything. Either wear an actual certified protective face mask same as, like a nurse or doctor would wear, otherwise don’t wear anything because it’s pointless.” S06
Self-efficacy	Factors contributing to high self-efficacy^b	Identified factors that build self-efficacy, including ease of access to face coverings, being required to wear face coverings, and prior experience wearing face coverings	“I agree. Yeah. Especially if they’re, like, provided by [university]” S09
Self-efficacy	Factors contributing to high self-efficacy^b		“Yes, I agree. I’ve purchased some non-medical grades. I’ve been able to get my hands on some others, the N95, whatever you call it. I’ve got, I’ve been able to get a pack of those. Just a few, just cloth coverings as well like the cloth ones with a simple filter in them. I’m definitely confident that I could.” S13
Physical distancing
Benefits	Reducing spread of germs and spread of COVID-19	The belief that physical distancing can contribute to decreased cases of COVID-19	“I think it would be less likely to get it and less likely to have exposure to germs for sure.” P15
	Reducing spread of germs and spread of COVID-19		“. . . if you’re maintaining distance you’re lowering the chance of contact, which will spread the disease or virus.” S06
	Necessary	The belief that physical distancing is a requirement to reduce the spread of coronavirus	“The way our doctor explained it was that, like, a sneeze can carry germs twenty feet. So, it seems like six feet really is necessary.” P15
	Necessary		“So, there needs to be some type of precaution. There needs to be something there.” S15
	Zone of safety	The belief that increased distance from others decreases the risk of contracting coronavirus	“. . . the social distancing, but at least give you another kind of a layer of protection if you will to keep the distance. So, the coughing or the sneezing doesn’t get on each other.” P17
	Zone of safety		“And they’re saying six feet is the distance that can keep you safe and if you’re at least maintaining that distance, then they’re not gonna be breathing on you and transferring anything that, you know, you don’t want” S14
	Good for public spaces	The act of stimulating hypervigilance when in spaces with others whose coronavirus status may be unknown	“I mean, I think it, especially if it’s something where you’re talking about outside, I think it gives them the ability to at least be around a group of people and being able to read people faces.” P06
	Good for public spaces		“I definitely think that’s a good idea in public spaces like Walmart or grocery stores or gas stations, or you’ve got tons of people coming in and out, but you don’t know from the next stranger, you don’t know where they’ve been, or what they’ve been doing.” S14
	Protecting others	The belief in distancing to be respectful and not spread the coronavirus to another person who may be more vulnerable in the population	“[not] sharing an illness, being respectful” P50
	Protecting others		“I’d say this one’s [inaudible] just mainly like if someone else is sick or like elderly [inaudible]. I gotta keep my distance from someone that’s older.” S09
Barriers	Forgetfulness^a	Parents believe students may forget about physical distancing	“I think the forgetfulness would be the biggest one.” P03
	Forgetfulness^a		“That, that is really harder than the face mask for that age group. Because once they get together. It’s like, they just they just forget. And I have tried to tell her that because I’m a believer in social distancing, and that that’s just hard. It’s hard for them to. It’s not like, she can’t gauge the space . . . but that is just really difficult for them to maintain . . .” P67
	Hard	Physical distancing can be awkward and hard to maintain	“I’d say it’s awkward to do.” P05
	Hard	Physical distancing can be awkward and hard to maintain	“. . . if you’re eating on campus, sometimes lines can get very congested. That may be a reason why it’d be harder to practice social distancing.” S05
	Invincibility^a	Parents believe students may not feel susceptible to contracting the coronavirus, therefore having a barrier to practice distancing	“I don’t think it’ll happen. I think this age group feels young and invincible. You talked to them, and they think that this is just like the flu and that people are exaggerating, people should go out and just get it just to go ahead and get it.” P04
	Invincibility^a		“Personally, I don’t think that. This, people in his age group will see, as much of an importance of staying six feet away . . .”
	Social needs and pressures	Physical distancing impacts engagement and interactions with friends and others	“That’s that’s kinda hard because the whole culture of colleges kind of, the social piece of it, and then also the educational piece, but the social piece, you’re away from your family or away from your home.” P03
	Social needs and pressures		“If I have friend to don’t expect, who think I’m really weird for standing way over there while they talk to them.” S25
	University administration response	From a policy perspective, people looked to university administration for a response to physical distancing	“But, you know, you also have to be prepared for when people get back to a classroom. When people go back to, you know, the cafeterias, get on campus and the dormitory. How are you going to ensure the athletic events are safe? And what’s gonna have to take place to, to provide that? You know, not only for the students, but for the parents for the faculty, for everybody.” P62
	University administration response		“Being in class, hopefully, there’s some social distancing in the classroom. I don’t, hopefully, I don’t have to sit right next to somebody.Hopefully, I don’t have to stand in front of the class and deliver a speech of some sort to, do allow myself to spread germs to the whole, to the whole classroom or something like that. Hopefully, hopefully the university can take care of some of those issues and hopefully everyone around me also respects those things because it’s not just about me and it’s about the school and how other students react to these protocols as well.” S13
	Comprehension of 6 ft	There is difficulty in grasping the guidelines of six feet distances between people	“He’s, he’s very smart, but I don’t think that he knows what six feet is, I don’t think any of us do . . .” P15
	Comprehension of 6 ft		“I just not really knowing what six feet from a person would be. That or if there was a thing where you physically couldn’t because you got pushed again. If you didn’t know, like, what six feet away from someone was.” S08
Response efficacy	Conditional effectiveness	Students and parents expressed belief in effectiveness depending on other factors	“Well, I think, you know, the six-foot distance was just it was established, just from kind of normal breathing without a mask. If someone sneezes across well, you know, game over. It’s like, but, yeah, I mean, that’s the whole purpose is to just keep that safe zone.” P54
Response efficacy	Conditional effectiveness		“I don’t think that it can guarantee it. I think that, yeah, if you also have to be wearing a mask, when you’re standing six feet apart and I don’t know if somebody’s mask can be faulty or like, too big for them. I mean, you could be yelling really loudly, but I think that it is I definitely think that it helps a lot. Just not guarantee, I wouldn’t say it would guarantee it.” S25
Self-efficacy	Out of student’s control	Other people contribute to a student’s confidence in physically distancing from others	“So, there’s just not enough space. In the room or whatever. And people and I can’t really control other people. If they come close to me.” S23
	Out of student’s control		“I feel like in, in workspaces and in class, classrooms it’s, it’s not necessarily just going be my responsibility, it’s how are other people around me going to follows things.” S13
	I can	Students believe they will try to do their best to social distance	“I think I’m kind of neutral [inaudible] six feet away from them. But I do feel like I can distance myself from them.” S08
	I can		“I agree with that, at least most of the time, I think it’d be again hard one hundred percent of the time, but I think everyone will try their best.” S24
Screening
Benefits	Early detection	Measures taken to identify COVID-19 through clinical assessments	“. . . hopefully, if he’s having symptoms, if he’s diagnosed earlier, hopefully, being aware, so he can take care of himself and not get worse.” P15
	Early detection		“I see the school being able to monitor people’s symptoms and be able to catch those that may have the virus sooner rather than later. If they are doing these daily screenings. I only see positives from it.” S05
	Prevent the spread	Practices employed to curtail the transmission of COVID-19 from person to person	“. . . one of the ways to stop the spread to know who has it. It’s actually the first step in stopping the spread.” P05
	Prevent the spread		“You possibly keep it from spreading to others, you can give the potential to that person to take time out to to go back and get healthy instead of spreading it to other people. So essentially, hopefully the benefit there is you keep the numbers down, keep more people from getting sick and hopefully slow the spread and help us get back to normal. Whatever normal will look like.” S14
	Decrease stigma	The reduction in societal negative connotations associated with COVID-19	“I do wonder a little bit about there’s a little bit of an embarrassment factor if you, you know you’re picked up, you know you got a fever. How do you make that not an embarrassing thing? And I think that was more a big deal when it first happened, than now. Maybe its just that people are expecting it and its more common place that you might have it. There shouldn’t be any shame if someone is running a fever, it shouldn’t be, oh you didn’t wash your hands enough or you didn’t wash your mask enough. Just that its going to happen.” P15
	Decrease stigma		“I think it sends a positive message. I think it just shows others like, hey, we don’t have to be afraid of this. This is, this is life, this is life, now, you know, even even with the social stigma, I’m willing to get out there and test every single day, if I have to, to show others like, hey, this is for you, this is for me, this is for grandma. S15
Barriers	Time	Limitations associated with scheduling beyond one’s control	“If they wake up late if they’re rushing to class. I don’t know if, if they’re saying they would do it at the dorm level, or if they would do it once they walk into class or, you know, where they would actually get screened or how, and with all the living, you know, options there are around campus. So, I would think if they’re running late or they’re rushing to get a test, to run to a test or you know, being documented for their presence in class if you know they’re, they’re just pushing to get there, so.” P17
Barriers	Time	Limitations associated with scheduling beyond one’s control	“The only thing that would keep me would possibly be being late to class.” S05
	Organization/logistics	Plans and policies for implementing strategies to reduce the spread of COVID-19 on campus	“I guess it would depend on the requirements. Like, if somebody is actually at the door, taking his temperature as he walks in. I don’t think it would be difficult, but if you’re requiring him to do, you know, I guess it would just depend on being planned and prepared, like, if you needed to, to go to school with a thermometer, or whatever it is . . .” P50
	Organization/logistics		“I don’t think, I don’t think there’s anything really big deal that might keep me from doing that myself as long as its fairly straightforward and simple to do. But if it was something that was, like, done on campus, and, like, you know, you have to do this, before you go to class, that might get kind of old, but see that happened. But, if you were, you know if it was, like, a, do it each day, kind of thing, and submitted online or something like that, I think that’s a lot easier to access probably a lot more straightforward. But I don’t think there’s any reason that I wouldn’t be willing to do that during this semester.” S14
	Missing class	The absence of a student from one or more courses in which he or she is enrolled	“So, but if he’s having to report it one, it would be more, and I’m not saying my son would do this, but others, like, you know, if there’s a reason that they need to be in class, or, you know, if they’re gonna miss and fall behind, they might not be quite as honest about their calculations. Like, you know, it would be almost the accountability of that. Like, how are you going to do that?” P50
	Missing class		“That is hectic and unnecessary. And I feel like it’s gonna make me late for class.” S09
	Forgetfulness^a	Memory deficit	“Forgetfulness not remembering to do it.” P03
	Forgetfulness^a	Memory deficit	“You know, you are talking about college boy that they tend to not be quite as organized. So, it just depends on time requirement to, like, when does he have to have this done by does it have to be turned in a certain time? Being organized being forgetful to do it.” P50
Response efficacy	Agreement	Affirmations that completing daily screenings prevent the spread of COVID-19	“I agree. And there’s just so much, you know, that we can do to help prevent the spread or slow the spread. Of course, we can’t stop it, but I think everything helps.” P15
	Agreement		“I would definitely agree that that would be the first step and helping the slow spread.” S14
	Slowing the spread	Actions resulting in the reduction in transmission of COVID-19 from person to person	“And there’s just so much, you know, that we can do to help prevent the spread or slow the spread. Of course, we can’t stop it, but I think everything helps.” P15
	Slowing the spread		“Like I said, we can’t avoid having cases new cases. I don’t think at least anytime soon, but the last thing that we want to see in our community in our state is like a massive outbreak so. Precaution, precaution, precaution.” S15
	Cautious optimism	Agreement that daily screenings could reduce the spread of COVID-19 with acknowledgments in the limitations of the singular approach to prevention	“And daily screening procedure would well, yeah, a daily screening procedure would help I think, for that. Well, as long as they stay in. I mean, it, it may maybe, I guess that’s a, maybe. Only if they comply with every other thing that they need to be doing, if there’s screened and found to be positive, it can be beneficial to a certain percentage. But maybe.” P69
	Cautious optimism		“I agree. Yes, I think it is a good way to try to monitor it. However, it may not, it’s not one hundred percent foolproof.” S05
Self-efficacy	Societal normalization	Prior experiences to practices that facilitate screening behaviors	“Like anytime you go to the doctor’s office you participate in it. Even going to get your hair done. You can get your temperature taken and they ask you all the questions. And if you hit one of them, it like oh come back another time for your hair appointment.” S08
Self-efficacy	Societal normalization		“I’m all for it, I do not have a problem with that at all. I went to the dentist and went to eat at Cracker Barrel last night, actually, the dentist took my temperature. Asked me a few questions. I feel fine. Have you gone out of the country the last few days, or the last few weeks? No, ma’am. Last night at dinner before you even walked in, are you experiencing any sickness? Sneezing, coughing, like, more than out of the regular because everybody sneezes that’s just human. No, ma’am, you know, have you been out of a country in the last few weeks? No ma’am.” S16
Staying home
Benefits	Preventing the spread	Actions taken to minimize the transmission of COVID-19	“Benefits that I see: one, you’re keeping yourself safe. You’re also keeping others safe when you stay home. It decreases the spread of the virus if you are having symptoms that are COVID-19-related and you possibly have it. That slows down the spread when you stay home and you self-quarantine.” S05
Benefits	Preventing the spread	Actions taken to minimize the transmission of COVID-19	“And you’re also at less risk to, to get other people sick whether it’s the flu or corona virus or whatever it might be. It’s a win, win.” S14
	Protecting others	Actions taken to decrease the likelihood of transmission of the virus to those who are not positive	“It’s really just caring for the other person. You’re making sure you’re not spreading your symptoms.” P17
	Protecting others		“Just reduce spread, I’m a people person so, you know, others, thinking about others. One person can spread to ten, fifteen, twenty people if it’s not done correctly and in severe cases way more than that you have to have that mindset of, you know, it’s not all about me, you know, we got to we got to knock this out together.” S15
	Taking time to recuperate	Energy devoted to the healing and recovery process	“Hopefully, they can rest and get better quicker. Been pushing it, you know, pushing their immune system, getting out and about, and still wearing down, you know, not being able to heal faster.” P17
	Taking time to recuperate	Energy devoted to the healing and recovery process	“You can rest, increase your rate of recovery” S06
Barriers	Obligations	The fear of missing commitments and responsibilities	“Obviously a concern about an exam or test or missing something in the classroom that she feels like she might not be able to to get the same information if she doesn’t go to class.” P56
	Obligations	The fear of missing commitments and responsibilities	“Things that might keep me from staying home will probably be like, if I had an on-campus job that I needed to be at, ‘cause not every college student can receive financial aid or scholarships. So, some students work. Also, if you need like, your essential needs, like grocery and these things.” S05
	GPA implications^a	The summative grade outcome of missed classes and/or content	“Probably the drive to succeed in the programs. I mean, he’s a straight “A” student and he does not wanna fall behind and he can’t fall behind. And so, I think it’s the fear of falling behind.” P03
	GPA implications^a		“He really cares about his GPA a lot.” P15
	Assignment parameters	The limitations associated with completing assignments for specific courses.	“If they have, like, a paper due if they have to turn in a hard copy, or they have a test to take and they have to physically show up for, if maybe they’ve had, let’s say they’ve had an illness and they’ve had several absences.” P17
	Assignment parameters		“. . . if I was feeling sick and I felt like I was in a class that I didn’t need to miss, then I can see how it would be hard to decide whether or not I needed to stay home because I know in a lot of classes, if you miss something in class, you might miss something pertaining to a new assignment coming up” S14
Response efficacy	Agreement	Affirmations that staying home prevents the spread of COVID-19	“Absolutely. Because it’s highly contagious.” P17
	Agreement		“I mean, that one’s actually a straight up agree. I guess that one would be an absolute, because if you’re not around anyone, you can’t spread it to anyone.” S06
	Preventing the spread of the virus	Actions resulting in the reduction in transmission of COVID-19 from person to person	“Because you’re not sharing germs, you’re not being in contact with people when spreading it without, you know, by talking to them, coughing, shaking hands, and touching doors, et cetera.” P50
	Preventing the spread of the virus		“But if you feel sick and you are sick, then staying at home is gonna prevent you from coming into contact with other people. So, you know, it’s easily enough said that if you’re not around people, you got a much less chance of giving it to somebody else. Plus, if you’re just feeling sick, like a like a daily headache or something, and you don’t have something, even if you stay home then and you don’t have something, you eliminate your chance of getting it from somebody else that you might not know is sick.” S14
Self-efficacy	Easy at first	Staying home is more challenging than anticipated	“Staying at home probably be pretty easy for an amount of time. I think, after a while, you [inaudible] being social and everything and not being in the same area. So, initially agreed [inaudible] easy. But after a time, pretty difficult and yeah.” S09
Self-efficacy	Easy at first	Staying home is more challenging than anticipated	“I can see the merit of it. Also, because I’ve been here this much in the state—not been sick but on the quarantine so long: boredom. Boredom.” S06
	Confident	Students feel confident in their ability to stay home when sick	“Me specifically, I do feel confident that I can stay home when I feel sick.” S18
	Confident		“My mom will make sure that I stay at home when I do get sick. So, I am confident, because I understand the importance of me staying at home.” S04
	Conditional confidence	Students expressed belief in their abilities depending on certain factors	“I will say neither, neither I’m not confident, nor am I not confident at again I think, how would the university handle its policy moving forward or missing class due to COVID related issues? So, I think that’s something we’re all gonna have to kind of knock out together that needs to be, I think that needs to be one of the top issues, right there. I know health is a big deal, but how are we still gonna take care of our students?” S15
	Conditional confidence		“I definitely think it depends on how sick, I do feel becuase if I just have a headache or stomachache, I mean I’m going to class, I’m going to my work, you know, just take some Advil, Tylenol, you know. Brush it off but definitely if I would feel worse than that, I would stay home unless I’m possibly on my death bed. I definitely would still continue my day, still continue my routine the best I could anyway.” S16

This theme applies only to parents. ^bThis theme applies only to students.

Cues to Action

In this study, cues to action were considered an act that stimulated consciousness about preventive health behaviors associated with the coronavirus. Although there was no direct question posed for cues to action, participants noted various cues, presented in Table 4. Participants indicated markers on the ground were helpful to understand physical distancing and to keep people adequately distanced. Group masking also provided a cue to action that helped establish the seriousness of the pandemic and normalcy. In addition, seeing other people wear a mask or use hand sanitizer provided a reminder to participants to be accountable to themselves and others. In summary, cues to action provided participants with a prompt to take action, an awareness of health behaviors taking place in society associated with the coronavirus, and personal accountability.

Table 4

Cues to Action to Engage in COVID-19 Prevention Behaviors

Definition	Quote
The act of stimulating consciousness about preventive health behaviors associated with the coronavirus	“. . . it sets an example for others to see if two people are social distancing. The others will see that and try to mirror that.” P05
	“I do think that just walking around town and when you see the lines everywhere, you think that helps out quite a bit because, I mean, it makes it easier. It’s like, something I don’t have to think about. I can just be like, oh, I just looked down on the ground. Oh, here’s the line. Let me stand here. It’s a lot helpful, more helpful when you can see those as grids to let you know where to be.” S05
	“I mean, you know, I know I really appreciated when the stores in [the city] put X’s down to show you. Okay, here’s your six-foot distance to stay between one another in line, to get in the door, to get in the checking out line or whatever that that was very helpful.” P54
	“I still see it as a visual sign that other people are taking it seriously and also it’s a visual sign that, okay. I’m I’m a little safer in this environment. Because I see other people wearing one, because I’m pretty sure everybody knows by now that it’s not for you, it’s for other people.” S18
	“I’m confident because I see large amounts people doing it.” S15
	“I saw a study on NBC probably about two or three days ago where they said it’s up to, like, sixty percent, could prevent spread if you wear, like, a face covering or face mask. So in a world where I’m twenty three years old and, you know, we’re all asymptomatic and it doesn’t matter, you know, it’s it’s I know it’s not gonna affect me in a sense or I feel like it’s not gonna affect me in a negative way, but I need to understand, hey, it doesn’t matter necessarily how it’s just affecting me, you know, how can we prevent the spread?” S15
	“I think again, just students and just and just a self-accountability on that and knowing that you, if you see, like, another person in front of you use hand sanitizer, then you kind of think. Oh, yeah that’s I need to do that too. So, it’s just a reminder and just seeing people around you do that as students or teachers or anyone.” S24

Campaign Development

The results of the study informed the university communications campaign. The following seven primary actions were communicated to students: wear a face covering, clean your hands often, observe physical distancing, stay home if you feel sick, sanitize surfaces, practice self care, and complete the daily screening. The campaign coincided with students returning to campus for the fall semester. A university press release initiated the start of the campaign and various tools were utilized to communicate the seven prevention behaviors including the use of an email signature graphic, mask up hashtag competition, yard signs, welcome back student packs in the residence halls, athletic event messaging, university emails, digital boards on campus, social media videos which included the university mascot, restroom mirror stickers, floor stickers, and a welcome back video that included the University President, Mayor, Athletics Director, Vice President for Student Affairs, Student Association President, the Director of the Diversity Center, and others.

Discussion

The interviews provided insights into key COVID-19 prevention behaviors. Participants noted key barriers to physical distancing with friends, such as forgetfulness and social pressures, highlighting that standing far away from friends and acquaintances while interacting is a new behavior and may feel awkward to some. To further understand reported prevention behaviors and inform communication efforts designed to increase these behaviors, we can return to constructs from the Health Belief Model (Rosenstock, 1974) and EPPM (Witte, 1992). We considered benefits of preventive behaviors, barriers to preventive behaviors, response efficacy, self-efficacy, and cues to action. According to the HBM, in order for someone to take a preventive action, a person needs to believe that the preventive action is beneficial and that they would not face substantial barriers. There also needs to be an “instigating event” (Rosenstock, 1974, p. 332) or cue to action. According to the EPPM, once a person perceives a moderate to high threat (determined by assessing susceptibility and severity), people evaluate the efficacy of the recommended response (determined by assessing response efficacy and self-efficacy). Our interviews yielded a nuanced understanding of these key constructs and novel findings that can inform communication efforts.

Benefits and Barriers

Across all behaviors, participants highlighted the benefit of preventing the spread of COVID-19 and protecting others, suggesting that communication appeals highlighting this benefit would be seen as plausible by this audience. Some behaviors, such as cleaning hands, wearing a face covering, and physical distancing, had the added perceived benefit of protecting the individual from COVID-19. We also observed important patterns related to barriers to protective action. Consistent with research from Scott and Vanick (2007), who found that forgetfulness was the most frequently cited reason for not washing hands, forgetfulness was a frequently cited barrier that highlights the need for reminders. Reminders could include physical signs on campus (e.g., physical distancing floor decals) or mobile push notifications. Second, accessibility was a major consideration for students and parents for behaviors that required materials (e.g., wearing a face covering). Based on this finding, colleges and universities should be encouraged to provide needed supplies to lower perceived barriers to use. Finally, social pressure was cited as an important barrier to behaviors that could be observed by others, such as wearing a face covering and physical distancing. Barile et al. (2020) found that seeing other people wearing a face covering strengthened the relationship between intention to wear a face covering and actual behavior. They attribute this to the power of descriptive norms and the way in which others’ behavior may serve as a cue to action. Barile et al. (2020) also acknowledge that wearing a face covering is a novel behavior that may be particularly susceptible to social forces. The same argument may be applied to physical distancing.

Response Efficacy and Self-Efficacy

Perceptions about response efficacy of and self-efficacy to take each recommended preventive behavior varied across individuals and behaviors, with participants often noting the conditional effectiveness of prevention behaviors and conditions needed to increase self-efficacy. For example, there was widespread acceptance of handwashing as a necessary but insufficient strategy for reducing the risk of COVID-19. Some students and parents perceived it as effective in reducing the risk of COVID-19, but others emphasized that it was only one part of a larger prevention strategy. Others were skeptical that cleaning hands would be effective. Their voices echo prior research by Botta et al. (2008), whose participants “felt that germs were everywhere and thus hand washing . . . did not really do that much to stop the spread [of germs]” (p. 377). Despite differing opinions on response efficacy, participants felt confident that they could wash hands or use sanitizer often as long as sanitizer and hand washing locations were available. This finding is consistent with prior research on hand hygiene from Botta et al. (2008), who found that college students believed they could wash their hands if they had soap and paper towels. On our campus, sanitizing stations with appropriate signage were set up throughout campus to serve as a cue to action to increase response efficacy and self-efficacy to clean hands. Hand sanitizer, both personal bottles and containers for large groups, was also made available in classrooms and other gathering spaces to increase efficacy regarding cleaning hands.

Similar themes in response efficacy and self-efficacy were observed for the other prevention behaviors. Participants believed face coverings could effectively reduce the spread of coronavirus, but participants noted the importance of compliance and perceived differences in the effectiveness of various types of masks. Factors contributing to self-efficacy to use face coverings included ease of access to face coverings and prior experience wearing a face covering. To address the use of face coverings as a protective measure to prevent the spread of COVID-19, the university developed and communicated policies via mass emails to simultaneously encourage mask wearing while emphasizing students’ rights to not wear masks as a gesture to highlight individual autonomy over one’s body. Faculty and staff were required to wear masks when near their colleagues or students. Participants saw physical distancing as somewhat effective in reducing spread, but self-efficacy to implement physical distancing varied, with students and parents voicing concerns about factors outside of the student’s control (e.g., spacing in classrooms). To encourage this behavior, the time between classes increased campuswide, classroom capacities were decreased, and students were only allowed to sit in designated seats at least three from others in classrooms and other gathering spaces. This information was conveyed via official university email correspondence. Screening for COVID-19 was seen as a practice that could slow, but not eliminate, the spread of COVID-19. Participants generally reported high levels of self-efficacy due to prior experiences with screening (such as at doctor’s offices) that normalized the behavior and reduced uncertainty. The university encouraged screening via yard signs, posters, news tickers, and recorded audiovisual advertisements to normalize testing. Randomized testing was also a practice employed by the student health center to gauge the incidence of COVID-19 on the campus. To inform various stakeholders of the COVID-19 morbidity data for the university, a webpage devoted to COVID-19 was developed and updated weekly. While not required, students who tested positive at off-campus locations were encouraged via the webpage and official university correspondence to share their results with the student health center to improve the accuracy of the morbidity data. Finally, participants reported high levels of confidence in the effectiveness of staying home when sick to prevent the spread of COVID-19. Some were also confident about their ability to stay home when sick, but others expressed concerns about missing class.

Limitations and Future Directions

The results of this study should be interpreted with the following limitations in mind. First, there are limitations related to generalizability. The participants were not randomly sampled from the university population, and, although the research team made efforts to recruit a diverse range of students and parents or guardians, those who chose to participate may not be fully representative of the university community. In addition, these results from a rural, southeastern university may not generalize to college students or parents and guardians in other regions. Future research should examine whether college student motivation to adopt preventive behaviors varies in relation to campus and community characteristics (such as size and location).

Second, there are limitations related to measurement and analysis. For example, differences observed between response efficacy themes for different behaviors could be due to the subtle shift in question wording when we asked about behaviors that protect others solely (e.g., staying home when sick) versus those that also protect the individual (e.g., cleaning hands). Interview responses may also be influenced by a social desirability bias; since interviewers were associated with campus health promotion, participants may have been reluctant to express negative thoughts associated with these efforts. Also, although the analysis team worked together to reach an agreement during each stage of the thematic analysis process, the data interpretations reflect the team’s perspective. We also acknowledge that the results of the thematic analysis represent the most prevalent beliefs and thus do not include every response.

Finally, we acknowledge that survey and interview data captured one period during a dynamic event. As science has progressed and recommendations have been updated, it is likely that beliefs about COVID-19 and prevention behaviors have changed as well. For example, the science related to the efficacy of wearing face coverings shifted over the months surrounding this research, and the benefits of wearing a face covering for the wearer became clearer after data were collected (Brooks & Butler, 2021). Future research should examine theoretical constructs related to mask-wearing considering newer efficacy data. In addition, because widely available COVID-19 testing and vaccines were not available at the time of data collection, our data do not include college students’ perceptions of testing and vaccines. Future research should examine factors that might influence these important prevention behaviors on the college campus.

Implications for Research, Practice, and Policy

By identifying beliefs that can inform theoretically-driven communication campaigns to prevent the spread of COVID-19 and other infectious respiratory illnesses, this mixed-methods study of college student and parent/guardian perceptions of COVID-19 prevention behaviors provides important insights that will be useful for health promotion research, practice, and policy.

First, this research provides important insights into how the Health Belief Model and EPPM can be applied to COVID-19 prevention behaviors. The most important contribution is the generation of a detailed list of perceived benefits, barriers, cues to action, and factors associated with response efficacy and self-efficacy for a variety of disease prevention behaviors. We used this list of perceived benefits, barriers, cues to action, and factors associated with efficacy to inform our theoretically-driven communication campaign. In particular, messaging was conveyed mainly through official university correspondence and highlighted the benefits of engaging in the desirable behaviors such as physical distancing, wearing face coverings, cleaning surfaces, and sanitizing hands. The messaging was deliberate in where it was placed and how it was conveyed in brief but attention-grabbing, culturally appropriate, and aesthetically appealing graphics. For example, to encourage physical distancing, floor stickers were placed in spaces in which there would be lines to receive services to ensure that relevant cues were in place to encourage the behavior. In addition, policies were conveyed via official university correspondence, and resources such as face masks and hand sanitizer were available for use in large gathering spaces. This in-depth understanding of the constructs and applicability of measures to align with the constructs can complement and inform future research that uses these theories.

The results also have important implications for health promotion practice and can be used to inform communication efforts to (a) increase infectious disease prevention behaviors among college students and (b) inform parents and other stakeholders about protocols to prevent the spread of the diseases on university campuses. Insights into factors that influence behaviors such as hand hygiene and face coverings may be useful in planning for prevention campaigns for infectious respiratory illnesses other than COVID-19, such as influenza. In addition, our results related to cues to action highlight the important role that communication, including simple signage, can play in prompting behaviors when message recipients already regard the behavior positively and have the self-efficacy to perform the behavior.

This research provides insight into the mental health needs of students. Social, mental, and emotional effects on well-being, because of social isolation, were noted by participants. Therefore, the campaign included a self-care component. This discovery underscores the importance for university administration, including health promotion specialists, to practice preventive and responsive mental health care for university students as they progress in their academic journey.

Finally, colleges can use these findings to inform college-level policies related to COVID-19 prevention. For example, informed by findings that students were concerned about academic penalties associated with staying home when sick, our university altered the attendance policy and communicated that change to students to increase students’ self-efficacy to adhere to recommendations. These policy changes were in addition to the aforementioned mask wearing, physical distancing in classrooms, and schedule adjustment policy changes due to COVID-19.

We acknowledge there are various divisions in the university setting. While our research team was part of a campus work group that aimed to assess and implement a communications campaign with multiple outputs, we acknowledge a more considerable team effort and action by various entities. Many individuals and other campus organizations were involved in implementing safety precautions, procedures, and preventive measures for our university campus simultaneously. Consequently, it is essential to have various levels of buy-in for prevention activities, including university administration, staff, faculty, parents, students, and other constituents.

Conclusion

Key benefits across the set of behaviors included reducing personal risk of contracting COVID-19 and reducing the spread of COVID-19 to others. Key barriers were forgetfulness, access, and social pressures. Students and parents viewed each recommended behavior as a conditionally effective piece of a larger strategy, and students were generally confident in their ability to implement prevention behaviors if they had access to needed resources. These data provide insights for future campaign development for the control of infectious diseases among college students.

Footnotes

ORCID iDs

Holli H. Seitz

Antonio J. Gardner

Leah B. P. Pylate

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Formative Research to Inform College Health Communication Campaigns About COVID-19 Prevention Behaviors

Abstract

Keywords

Prior Research to Inform Covid-19 Communication Campaigns

Theoretical Framework

Health Belief Model

Extended Parallel Process Model

Method

Participants

Instruments

Survey

Interview

Analysis

Results

Consequences

Benefits, Barriers, Response Efficacy, and Self-Efficacy

Cues to Action

Campaign Development

Discussion

Benefits and Barriers

Response Efficacy and Self-Efficacy

Limitations and Future Directions

Implications for Research, Practice, and Policy

Conclusion

Footnotes

ORCID iDs

References